By Insiya Bhalloo & Kai Ian Leung
Take a deep breath: Put your hand on your belly and imagine a big red balloon expanding in your belly. Now exhale and say “aaaaah” loudly. This diaphragmatic breath will allow you to project your voice without straining your delicate vocal folds. Now practice your upward vocal glides: aaaaah and downward vocal glides: aaaaah, using your deep breathing as a projector. – Sarah Awde
Take another deep breath: take a moment to settle in your seat, with your feet firmly on the floor and hands in your lap, elongating the spine and embodying a stable and erect posture. Next, acknowledge this present moment, and all this moment has to offer. Ask yourself, “What is my experience in this present moment?” and tune into any thoughts that may come to mind. – Sucheta Heble
These two speech-language pathologists (SLPs), Sarah Awde and Sucheta Heble, both primarily conduct therapy for older adults in Canada using a very common piece of equipment (probably one you are using right now): a computer. Telerehabiliation, or telerehab for short, is a means to deliver rehabilitation at a distance and is commonly done via computer or smartphone (1). While Sarah provides speech-language therapy to older adults with Parkinson’s Disease (PD), Sucheta provides mindfulness-based therapy to older adults with acquired brain injury (ABI).
Did you know that over 100,000 Canadians currently live with PD? (2) Commonly thought of as a motor-cognitive condition, PD’s lesser-known effects concern swallowing, chewing, speaking, voice-intonation and perception (3). Sarah conducts voice assessments and speech therapy at GetLOUD! Therapy for adults with this increasingly prevalent neurodegenerative condition (4). For Sarah, telerehab facilitates evidence-based practice: the Lee Silverman Voice Training (LSVT) program, a “gold standard” in PD treatment which recommends frequent therapy sessions (two to three times per week). Sarah uses secure communications platforms such as Zoom, and equipment measuring speech quality, such as voice pitch, loudness, and sound pressure. These tools allow Sarah to provide intensive speech-therapy and voice training to Canadians with PD living in rural areas or with mobility issues, who can now access speech-language therapy even during harsh Canadian winters.
Sucheta, a registered SLP at the Toronto Rehab Institute, conducts weekly group relaxation and mindfulness therapy for older adults with ABI, often using the Cisco Jabber communication platform. The theme-based sessions focus on thought and emotional awareness, goal development and enhanced accessibility to group-based discussions and social engagement with others with ABI. The central themes can be referred to by the therapist to limit participant distractions (caused by ABI-related memory issues), reining discussion to the main topic.
Telerehab: The good news
While speech-language and mindfulness telerehab have increased access to intensive, evidence-based resources for elderly populations, these therapies also reduce the economic burden of costly in-person therapy sessions (1). Both interfaces (Zoom and Cisco Jabber) facilitate individual and group social-communicative interactions, from the comfort and privacy of one’s home. By using these secure platforms, teletherapists can overcome outrageous software licensing costs and the e-security threats associated with less confidential communications platforms such as Skype.
From a business standpoint, GetLOUD! benefits from avoiding overhead rent costs of a storefront and from utilizing management software, like Jane, which facilitates scheduling, invoicing, and administrative tasks. Cost savings are passed along to the clients and the environment in the form of reduced transportation expenses. In mindfulness therapy, the privacy and comfort of the home (as opposed to an unfamiliar hospital) may be the best therapeutic environment within which to practice this modality. For individuals with mobility or health issues, telerehab facilitates access to therapy without having to navigate the transit system. This convenience allows individuals to focus on therapy goals more independently, and most importantly, on their health and safety.
Limitations with current regulations in Ontario
It isn’t all picture (or pitch) perfect, however. Both Sucheta and Sarah emphasize the need for clearer guidelines from governing bodies surrounding what is needed to practice telerehab effectively. Mindfulness therapy does not have a specific federal or provincial-level governing body informing how practice should be conducted through online platforms. The current position statement from the governing body College of Audiologists and Speech Language Pathologists of Ontario (CASLPO) reminds members who practice telerehab to adhere to the Code of Ethics, the core principles of responsible practice (5).
One key principle is for SLPs to ensure that the primary encounter be “face-to-face” (5). This is satisfied by including live interactive videoconferencing with both audio and visual components. Like in-person therapy, client confidentiality and therapy-data preservation is required for telerehab. However, no recommendation has been made regarding which teleconferencing platforms enable regulatory compliance. Also missing are additional guidelines such as which therapy populations and therapy goals are most conducive or least likely to benefit from telerehab.
While both Sarah and Sucheta do conduct an initial in-person encounter for their services, follow-up sessions can be done via telepractice essentially anywhere within Ontario. Problematically, however, CASLPO also requires that the SLP be licensed wherever the client is located. Consequently, if a client relocates to a different province/country even temporarily (e.g., road trip, business meeting), the SLP needs additional licensure to practice. This restriction limits access to affordable, frequent therapy for clients who may need to travel regularly. While this CASLPO requirement is generally feasible for inter-provincial licensure, it is complicated between countries — even between those with trade/professional agreements such as Canada and the US. With mobility and connections increasing through globalization, it is the Canadian client who ultimately suffers the consequences of current regulatory restrictions.
Another CASLPO guiding principle lacking specific guidance on its application to telerehab is that the standard of care received via telepractice should be the same as that given in-person (5). There is currently no standardized means or research to determine this equivalency, which raises the question of who is responsible for ensuring that therapy standards for telerehab are similar to in-person therapies. CASLPO leaves this responsibility to the judgment of each teletherapist. They do not specify whether this is also the responsibility of federal regulatory bodies (Speech-Language and Audiology Canada), provincial governing bodies (CASLPO), and/or employers such as hospitals or private clinics.
The importance of informed consent and individual-specific therapy is emphasized by CASLPO, as evident by their statement on client choice and the responsibility of the SLP member to provide direct services or locate alternatives (5). However, a support tool that is greatly needed but not yet facilitated by CASLPO, is a telerehab-specific network of practicing SLPs that meets jurisdictional and therapy goal requirements. Above facilitating connections, this network could also be used by SLPs seeking partner SLPs who can provide one-time, in-person assessments or intensive therapy to clients with complex communication or swallowing goals that cannot be addressed via telerehab.
For individuals with mobility or health issues, telerehab facilitates access to therapy without having to navigate the transit system.
An inadequate replacement of in-person treatment
While it would be tempting to skip the clinic altogether, some things just require that in-person connection. Outreach and public education is one example. Sarah regularly holds workshops with Parkinsons’ Canada and Parkinson Society Southwestern Ontario chapters, which also raises awareness of her telepractice.
Mindfulness and SLP telerehab has its challenges; only certain types of clients, such as those with independent communication and cognitive skills, benefit from the online modality. People who have difficulty attending to information, distracting behaviours, and/or have side conversations, take away from the quality of service. In Sucheta’s sessions, establishing ground rules and providing clear expectations are ways to mitigate issues that come with group telerehab. Technology challenges can also affect web-based services. Sarah also offers “tech 101” to set-up and facilitate computer/internet access, as well as familiarity with the interface.
Sucheta’s mindfulness sessions can only host a small group given its current interface. This limits the access of the service for those needing this outpatient service. Similarly, Sarah’s in-person workshops reach only those who can come to the venue. Development of larger group telepractice hosting is sorely needed.
For telerehab, specific standards and therapy recommendations pertaining to individual fields are needed. Educational and practical resources to support independent speech-language and mindfulness therapists would help clear the doubts surrounding this new frontier of telerehab. The best practice for SLPs navigating telerehab is to contact CASLPO directly for clarification. Telepractice groups on social media have also been a way to connect with peers in similar situations. Provision of further telerehab guidelines from regulatory bodies is needed for both SLPs and mindfulness teletherapists to ensure therapy uniformity and efficacy across regional and cyber borders.
Remember the exercises from the beginning? Now imagine in the expanded future of telerehab, that after they were introduced by an in-person facilitator, the therapy exercises were now group-based instead of just being you with your computer. How much better might your future recovery be with interactive, accessible, and long-term SLP and mindfulness telerehab, all outlined by clear practice guidelines?
Featured illustration by Daniela Casas for rehabINK.
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To refer to this article, it can be cited as:
Bhalloo I & Leung KI. Clinical innovation or buzzword? Exploring telerehab in Speech-Language Pathology and mindfulness therapy. rehabINK. 2020;8. Available from: https://rehabinkmag.com
- Parkinson’s Disease [Internet]. UCB Canada; 2019 [cited 2019 Nov 7]. Available from: https://www.ucb-canada.ca/en/Patients/Conditions/Parkinson-s-Disease
- Lieberman P, Kako E, Friedman J, Tajchman G, Feldman LS, Jiminez EB. Speech production, syntax comprehension, and cognitive deficits in Parkinson’s disease. Brain and language. 1992;43(2):169-89.
- Dorsey ER, Elbaz A, Nichols E, Abd-Allah F, Abdelalim A, Adsuar JC et al. Global, regional, and national burden of Parkinson’s disease, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2018;17(11):939-53.
- Theodoros DG. Telerehabilitation for service delivery in speech-language pathology. Journal of Telemedicine and Telecare. 2008;14(5):221-4.
- Use Of Telepractice Approaches In Providing Services To Patients/Clients [Internet]. Ontario, Canada: CASLPO; 2004 [updated 2014 May; cited 2019 Nov 7]. Available from: http://www.caslpo.com/sites/default/uploads/files/PS_EN_Use_of_Telepractice_Approaches_in_Providing_Services_to_Patients_or_Clients.pdf